| NPI | 1023352853 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MO 2019038872) |
| Additional Taxonomies | 163WP0809X Registered Nurse, Psych/Mental Health, Adult (Licence: KS 53-76164-082) |
| Enumeration Date | 2012-11-16 |
| Last Update Date | 2021-06-22 |